The Learning Curve for Robot-Assisted Radical Cystectomy

Objective: Robot-assisted radical cystectomy has the potential to cure patients from bladder cancer while offering the benefits of minimally invasive surgery. We sought to evaluate the learning curve for this technically demanding procedure. Materials and Methods: Robot-assisted radical cystectomy was attempted in 100 consecutive patients. An IRB-approved review of our robot-assisted radical cystectomy database was conducted. Total operative (OR) time, cystectomy time, pelvic lymph node dissection (PLND) time, estimated blood loss (EBL), margin positivity, complications, and length of hospital stay were compared among patients divided into 4 cohorts of increasing surgical experience. Scattergrams and continuous curves were ploted to develop a robotic cystectomy learning curve. Results: Overall OR time decreased from 375 minutes in cohort 1 to 352 minutes in cohort 4, with less than 1% change in OR time after case 16. Time from incision to bladder extirpation decreased from 187 minutes in cohort one to 165 minutes in cohort 4. Time for PLND increased from 44 minutes in cohort 1 to 77 minutes in cohort 4. Lymph node yield increased from 14 nodes in cohort 1 to 23 nodes in cohort 4. Positive surgical margins decreased from 4 patients in cohort 1 to 0 patient in cohort 4. The complication rate had no change from 9 patients in cohort 1 to 9 patients in cohort 4. Conclusion: Operative results and oncologic outcomes for robot-assisted radical cystectomy constantly improve as the technique evolves.